1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See About this guideline for details.

1.1.6 Refer people suspected of having MS to a consultant neurologist. Speak to the consultant neurologist if you think a person needs to be seen urgently.

1.1.7 Only a consultant neurologist should make the diagnosis of MS on the basis of established up‑to‑date criteria, such as the revised 2010 McDonald criteria[2], after:

assessing that episodes are consistent with an inflammatory process

excluding alternative diagnoses

establishing that lesions have developed at different times and are in different anatomical locations for a diagnosis of relapsing–remitting MS

establishing progressive neurological deterioration over 1 year or more for a diagnosis of primary progressive MS.

1.1.8 If a person is suspected[2] of having MS but does not fulfil the diagnostic criteria, plan a review. Discuss the timing of the review with the person and ensure they know who to contact for advice if they develop further neurological symptoms or if current symptoms worsen.

1.1.9 Offer people suspected of having MS, information about support groups and national charities.

Optic neuritis and neuromyelitis optica

1.1.10 If a person has an episode of isolated optic neuritis, confirmed by an ophthalmologist, refer them to a consultant neurologist for further assessment.

1.1.11 Diagnosis of neuromyelitis optica should be made by an appropriate specialist based on established up‑to‑date criteria.

1.2 Providing information and support

1.2.1 NICE has produced guidance on the components of good patient experience in adult NHS services. This includes recommendations on communication, information and coordination of care. Follow the recommendations in Patient experience in adult NHS services (NICE clinical guideline 138).

Information at the time of diagnosis

1.2.2 The consultant neurologist should ensure that people with MS and, with their agreement their family members or carers, are offered oral and written information at the time of diagnosis. This should include, but not be limited to, information about:

what MS is

treatments, including disease‑modifying therapies

symptom management

how support groups, local services, social services and national charities are organised and how to get in touch with them

1.2.3 Discuss with the person with MS and their family members or carers whether they have social care needs and if so refer them to social services for assessment. Ensure the needs of children of people with MS are addressed.

1.2.4 Offer the person with MS a face‑to‑face follow‑up appointment with a healthcare professional with expertise in MS to take place within 6 weeks of diagnosis.

Ongoing information and support

1.2.5 Review information, support and social care needs regularly. Continue to offer information and support to people with MS or their family members or carers even if this has been declined previously.

1.2.6 Ensure people with MS and their family members or carers have a management plan that includes who to contact if their symptoms change significantly.

1.2.7 Explain to people with MS that the possible causes of symptom changes include:

another illness such as an infection

further relapse

change of disease status (for example progression).

1.2.8 Talk to people with MS and their family members or carers about the possibility that the condition might lead to cognitive problems.

1.2.9 When appropriate, explain to the person with MS (and their family members or carers if the person wishes) about advance care planning and power of attorney.

1.3 Coordination of care

1.3.1 Care for people with MS using a coordinated multidisciplinary approach. Involve professionals who can best meet the needs of the person with MS and who have expertise in managing MS including:

1.5.6 Advise people that aerobic, balance and stretching exercises including yoga may be helpful in treating MS‑related fatigue.

1.5.7 Do not use vitamin B12 injections to treat fatigue in people with MS.

1.5.8 Consider a comprehensive programme of aerobic and moderate progressive resistance activity combined with cognitive behavioural techniques for fatigue in people with MS with moderately impaired mobility (an EDSS[5] score of greater than or equal to 4).

Mobility

1.5.9 Ensure people with MS and mobility problems have access to an assessment to establish individual goals and discuss ways in which to achieve them. This would usually involve rehabilitation specialists and physiotherapists with expertise in MS.

1.5.10 Do not use fampridine to treat lack of mobility in people with MS because it is not a cost effective treatment[6].

Treatment programmes for mobility and/or fatigue

1.5.14 Help the person with MS continue to exercise, for example by referring them to exercise referral schemes.

1.5.15 If more than one of the interventions recommended for mobility or fatigue are suitable, offer treatment based on which the person prefers and whether they can continue the activity after the treatment programme ends.

Spasticity

1.5.16 In people with MS assess and offer treatment for factors that may aggravate spasticity such as constipation, urinary tract or other infections, inappropriately fitted mobility aids, pressure ulcers, posture and pain.

1.5.17 Encourage people with MS to manage their own spasticity symptoms by explaining how doses of drugs can be adjusted within agreed limits.

1.5.18 Ensure that the person with MS:

has tried the drug at an optimal dose, or the maximum dose they can tolerate

stops the drug if there is no benefit at the maximum tolerated dose

has their drug treatment reviewed at least annually once the optimal dose has been reached.

1.5.19 Consider baclofen or gabapentin[7] as a first‑line drug to treat spasticity in MS depending on contraindications and the person's comorbidities and preferences. If the person with MS cannot tolerate one of these drugs consider switching to the other.

1.5.20 Consider a combination of baclofen and gabapentin[7],[8] for people with MS if:

individual drugs do not provide adequate relief or

side effects from individual drugs prevent the dose being increased.

1.5.21 Consider tizanidine or dantrolene as a second‑line option to treat spasticity in people with MS.

1.5.22 Consider benzodiazepines as a third‑line option to treat spasticity in MS and be aware of their potential benefit in treating nocturnal spasms.

1.5.23 Do not offer Sativex to treat spasticity in people with MS because it is not a cost effective treatment[9].

1.5.24 If spasticity cannot be managed with any of the above pharmacological treatments, refer the person to specialist spasticity services.

Pain

1.5.30 Be aware that musculoskeletal pain is common in people with MS and is usually secondary to problems with mobility and posture. Assess musculoskeletal pain, offer treatment to the person and refer them as appropriate.

Cognition including memory

1.5.31 Be aware that the symptoms of MS can include cognitive problems, including memory problems that the person may not immediately recognise or associate with their MS.

1.5.32 Be aware that anxiety, depression, difficulty in sleeping and fatigue can impact on cognitive problems. If a person with MS experiences these symptoms and has problems with memory and cognition, offer them an assessment and treatment.

1.5.33 Consider referring people with MS and persisting memory or cognitive problems to both an occupational therapist and a neuropsychologist to assess and manage these symptoms.

1.6 Comprehensive review

1.6.1 Ensure all people with MS have a comprehensive review of all aspects of their care at least once a year.

1.6.2 Ensure the comprehensive review is carried out by healthcare professionals with expertise in MS and its complications. Involve different healthcare professionals with expertise in specific areas of the review if needed.

1.6.3 Tailor the comprehensive review to the needs of the person with MS assessing:

1.6.7 Ensure people with MS and severely reduced mobility are regularly assessed and reviewed for risk of contractures.[14]

1.6.8 Check people with MS and severely reduced mobility at every contact for areas at risk of pressure ulcers (see Pressure ulcers NICE clinical guideline 179).

1.6.9 Discuss the care provided by carers and care workers as part of the person's care plan. Ensure carers know about their right to a local authority carer's assessment and how to apply for one.

1.6.10 Refer people with MS to palliative care services for symptom control and for end of life care when appropriate.

1.7 Relapse and exacerbation

Treating acute relapse of MS with steroids

1.7.1 Develop local guidance and pathways for timely treatment of relapses of MS. Ensure follow‑up is included in the guidance and pathway.

1.7.2 Non‑specialists should discuss a person's diagnosis of relapse and whether to offer steroids with a healthcare professional with expertise in MS because not all relapses need treating with steroids.

Recognising a relapse

1.7.3 Diagnose a relapse of MS if the person:

develops new symptoms or

has worsening of existing symptoms

and these last for more than 24 hours in the absence of infection or any other cause after a stable period of at least 1 month.

Treating a relapse

1.7.8 Consider intravenous methylprednisolone 1 g daily for 3–5 days as an alternative for people with MS:

in whom oral steroids have failed or not been tolerated or

who need admitting to hospital for a severe relapse or monitoring of medical or psychological conditions such as diabetes or depression.

1.7.9 Do not prescribe steroids at lower doses than methylprednisolone 0.5 g daily for 5 days to treat an acute relapse of MS.

1.7.10 Do not give people with MS a supply of steroids to self‑administer at home for future relapses.

Information about treating a relapse with steroids

1.7.11 Discuss the benefits and risks of steroids with the person with MS, taking into account the effect of the relapse on the person's ability to perform their usual tasks and their wellbeing.

1.7.12 Explain the potential complications of high‑dose steroids, for example temporary effects on mental health (such as depression, confusion and agitation) and worsening of blood glucose control in people with diabetes.

1.7.13 Give the person with MS and their family members or carers (as appropriate) information that they can take away about side effects of high‑dose steroids in a format that is appropriate for them.

1.7.14 Ensure that the MS multidisciplinary team is told that the person is having a relapse, because relapse frequency may influence which disease‑modifying therapies are chosen and whether they need to be changed.

Medical, therapy and social care needs at time of relapse or exacerbation

1.7.15 Identify whether the person having a relapse of MS or their family members or carers have social care needs and if so refer them to social services for assessment.

1.7.16 Offer inpatient treatment to the person having a relapse of MS if their relapse is severe or if it is difficult to meet their medical and social care needs at home.

1.7.17 Explain that a relapse of MS may have short‑term effects on cognitive function.

1.7.18 Identify whether the person with MS having a relapse or exacerbation needs additional symptom management or rehabilitation.

1.8 Other treatments

Vitamin D

1.8.1 Do not offer vitamin D solely for the purpose of treating MS.

Omega fatty acids compounds

1.8.2 Do not offer omega‑3 or omega‑6 fatty acid compounds to treat MS. Explain that there is no evidence that they affect relapse frequency or progression of MS.

[3] 'Chronic neurological disease: conditions in which respiratory function may be compromised, due to neurological disease (e.g. polio syndrome sufferers). Clinicians should consider on an individual basis the clinical needs of patients including individuals with cerebral palsy, multiple sclerosis and related or other similar conditions; or hereditary and degenerative disease of the nervous system of muscles; or severe disability.' (Department of Health 2013)

[4] At the time of publication (October 2014), amantadine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

[6] This recommendation does not apply to people who have already started treatment with fampridine in the NHS who should be able to continue treatment until they and their NHS clinician think it appropriate to stop.

[7] At the time of publication (October 2014), gabapentin did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

[9] This recommendation does not apply to people who have already started treatment with Sativex in the NHS who should be able to continue treatment until they and their NHS clinician think it appropriate to stop.

[10] The subjective sensation of horizontal and/or vertical movement of the visual field that is unexplained by movement of the observer or environment.

[11] At the time of publication (October 2014), memantine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

[13] At the time of publication (October 2014), amitriptyline did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

[14] A contracture is a shortening in the soft tissues (that is, tendons, muscles or ligaments) around a joint that limits the passive (and active) range of movement at that joint.